Get Ca Gold Coast Health Plan Direct Referral Form 2022-2025

Filling out the CA Gold Coast Health Plan Direct Referral Form online is a straightforward process that allows referring providers to facilitate referrals to in-network specialists efficiently. This guide provides step-by-step instructions to help you complete the form accurately and effectively.

Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to access the referral form and open it for editing.
2. Begin by filling in the patient information section. Enter the patient's name, date of birth, mailing address, CIN number, age, and phone number. Ensure that all information is accurate to avoid any delays.
3. In the primary care provider (PCP) section, provide the name of the PCP, the facility name, the facility's address, and contact phone number. This identifies the healthcare professional overseeing the patient's care.
4. Select whether the referral is for an in-network or out-of-area provider. Fill in the ordering provider's details, including name, phone, fax, address, specialty, city, state, zip code, TIN, NPI, and an office contact.
5. Complete the referral specialist information section. Input the specialist's name, phone, fax, address, specialty, city, state, zip code, TIN, NPI, and office contact details.
6. Finally, obtain the provider's signature and the date issued. This validates the referral request before it is sent.
7. Once all fields are completed, users can save changes, download, print, or share the completed form as needed for submission.

Complete your CA Gold Coast Health Plan Direct Referral Form online today!